Provider Demographics
NPI:1487324398
Name:POLYMERASE LABS LLC
Entity type:Organization
Organization Name:POLYMERASE LABS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LAB DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MALOUF
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-793-2150
Mailing Address - Street 1:4549 FAIRWAY AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-1606
Mailing Address - Country:US
Mailing Address - Phone:817-793-2150
Mailing Address - Fax:
Practice Address - Street 1:405 N RIDGEWAY DR STE H
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-5130
Practice Address - Country:US
Practice Address - Phone:817-793-2150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory